Dementia doctors, provinces differ on question of advance consent in MAID

TORONTO — While proposed new federal legislation would allow advance requests for medical assistance in dying, the stark difference in opinion between two provinces highlights an ongoing debate about what constitutes true consent among people who have dementia.

Justice Minister Sean Fraser introduced a bill on Tuesday to decriminalize providing MAID to people with dementia and other conditions that take away the capacity to consent if they ask for it in advance while they’re still mentally capable.

Bill C-41 states that “a person would have to be experiencing intolerable suffering at the time MAID is provided, even if all the conditions in their advance request have been met.”

It’s up to provincial governments to decide whether — and how — to allow people to make advance requests and have those wishes fulfilled in the future.

The positions of two provinces are already clear. Quebec legalized advance requests in 2024.

Alberta, on the other hand, passed legislation last March that bars advance requests — and the federal government’s legislation won’t change that position, said Maddison McKee, press secretary to Adriana LaGrange, the province’s minister of hospital and surgical health services.

“Ending a person’s life when they can no longer confirm their wishes raises profound concerns about consent and the protection of vulnerable people, which is why the safeguards we enacted last spring will remain in place,” McKee said in an email on Oct. 7.

Quebec had 3,463 registered advance requests as of Oct. 4 this year, Marie-Christine Patry, spokesperson for the province’s ministry of health and social services, said in an email.

The number of advance requests that have led to MAID being carried out in Quebec is not available, but is expected to be included in a report by the province’s commission on end-of-life care later this fall, she said.

Dying with Dignity has said that without advance requests in the rest of country, people with dementia have lost precious time with loved ones because they have chosen to receive MAID while they still have the ability to consent, instead of risking not being able to die when their condition has deteriorated to an intolerable state of suffering.

Earlier in October, Fraser said the Liberal government believes allowing advance requests is the right thing to do and reflects the will of many Canadians.

“I have conversations with people who’ve received a diagnosis of early onset Alzheimer’s, who want desperately to be able to know that they’re not going to subject their families to pain and suffering,” he said.

The minister acknowledged that advance requests will spark debate and discussion in the provinces over “the next number of months and years.”

The issue is “complicated,” said Dr. Samir Sinha, a geriatrician and clinical scientist at Sinai Health and University Health Network in Toronto.

Sinha, who was part of an expert panel that looked at the issue, said the trickiest cases will be when someone makes an advance request for medically assisted death to be administered when their dementia takes certain effects — such as not being able to recognize their children — but when that condition happens and it’s time for MAID, the patient seems happy in their current life.

“(The question is) does your present self and your present views truly reflect what your future self and future views will actually be? Nobody knows,” Sinha said.

For him, there’s no issue if the patient made an advance request for MAID and is clearly not experiencing a good quality of life.

“There’s no happiness, and this is kind of what you said would be intolerable suffering, and we all see it. Well, there’s clarity there,” Sinha said.

When it’s not so “black or white” and the person’s quality of life is more of a grey area, “that’s where I get nervous,” he said.

Dr. Catherine Ferrier, a geriatric physician at McGill University Health Centre in Montreal who treats patients with dementia, said she simply doesn’t see how advance consent to death can be valid from a medical ethics perspective.

“This is like signing a paper trying to imagine yourself several years down the road when you’re in a different condition and what might be troubling you at that time and saying, ‘I predict that it will be so bad that I would prefer to be dead.’ And there’s a lot of assumptions there,” said Ferrier, who is president of the Physicians’ Alliance Against Euthanasia.

Instead, the focus should be on providing more services to patients with dementia and their families so they can live comfortable and fulfilling lives, as well as ensuring the staff caring for them — both in long-term care and home care — are properly trained, she said.

According to its website, the alliance sees “any law allowing doctors to intentionally end the life of their patients as contrary to the goals of medicine and the good of our patients, especially the most vulnerable and those who cannot speak for themselves.”

But Dr. Laurent Boisvert, a family and emergency physician who provides MAID in Quebec, said the opposite is true — that someone can only truly give consent when they have the mental capacity to do so.

A patient’s advance request for MAID reflects that person’s true wishes — even if they “seem” to be happy later when dementia has taken away what they valued, he said.

“(That’s) the real suffering,” said Boisvert, who is the president of Association québécoise pour le droit de mourir dans la dignité — Quebec’s equivalent to Dying with Dignity.

He said that when he prepares advance requests with patients who have dementia, it brings them great relief.

“When everything is complete, I said to them, ‘now you forget that and have fun. When you will have (a) big problem, your advance request is there as you ask(ed), and that is what you want,'” he said.

“At this moment they say, ‘oh doc, phew, I’m really fine with that and I’m very happy that I can put that behind me.”

In Quebec, advance requests must specify effects of their illness that would signal they would want MAID at that time.

The most common conditions Boisvert sees listed by patients with dementia include no longer being able to recognize their family, not being able to go to the toilet themselves, not being able to eat without assistance, not knowing where they are and becoming aggressive.

In a technical briefing on Tuesday, government officials said that two physicians or nurse practitioners would assess the patient at the time their advance request conditions for MAID have been met to determine if they are experiencing intolerable suffering.

If a person seems happy at that time, that’s “one piece of information that a practitioner will have to take into consideration,” they said.

Quebec also allows people making advance requests to designate one or two “trusted third person(s)” who know the patient’s wishes and will advocate to make sure they are known and respected by health and social service providers. They can inform the patient’s care team if they see the conditions outlined in the advance request happening.

A physician or specialized nurse practitioner then assesses the patient to decide if they have reached the stage of “unbearable physical or psychological suffering that cannot be relieved under conditions considered tolerable,” according to the Quebec government website. A second doctor or nurse practitioner must confirm the assessment.

This report by The Canadian Press was first published Oct. 27, 2026.

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